International Journal of Epidemiology
2
© International Epidemiological Association 1986
Letters to the Editor
A Dictionary of Epidemiology
From JOHN M LAST
Sir—The preparation of A Dictionary of Epidemiology
was a cooperative effort in which epidemiologists from
many parts of the world contributed ideas, definitions,
etc. The resulting work, while useful, was flawed. Some
Department of Epidemiology and Community Medicine, School of
Medicine, University of Ottawa, 451 Smyth Road, Ottawa, Canada,
K1H 8M5.
Maternal mortality in developing countries
From TIES BOERMA
Sir—In two recent letters, Thuriaux and Lamotte1'2
point out that hospital-based statistics of maternal
mortality are overestimating national maternal
mortality, as maternal deaths are more likely to be
recorded than births. They argue that the traditionally
used method of estimating maternal mortality is mis-
leading and calculate that, in Niger, the institutional
maternal mortality ratio decreased from 519 to 420 per
100000 live births between 1980 and 1982, whereas the
national ratio, based on expected number of live births,
increased from 135 to 166.
Their point is clear and important but the arguments
are inaccurate. The key issue is the level of coverage of
births by health institutions. If the latter is low, such as
in most African countries (average 34<%)3 the
population-based maternal mortality ratio is also low,
as it is calculated as the product of institutional
maternal mortality ratio and obstetric coverage by
institutions assuming that coverage of maternal deaths
is 100%. However, the lower the proportion of births
covered by institutions the more uncertain is the
estimate.4 In such areas, many women never reach a
United Nations Children's Fund, Eastern Africa Regional Office, PO
Box 44145, Nairobi, Kenya.
277
Vol. 15, No.
Printed in Great Britain
of the definitions are quite inadequate and a few are
misleading. Some important terms were left out, and
some trivia were included.
A revised edition, to correct these shortcomings, is
now being prepared. Epidemiologists and others who
would like to be included in a circulation list of draft
definitions, or who have comments or suggestions to
offer, are invited to communicate with John Last at the
address given.
health facility and some die at home. Equally true, such
facilities are likely to have a high number of
complicated cases and subsequent deaths. In areas with
relatively high obstetric coverage it is more likely that
most high risk or complicated cases have access to
health facilities and mortality at home is probably
lower than institutional mortality.
In Niger, obstetric coverage was only 26% in 1980,
but increased considerably over two years to 39% in
1982. Therefore, even though the number of maternal
deaths in health facilities increased from 373 to 484, the
institutional maternal mortality ratio decreased from
519 to 420 per 100000 live births. On the other hand,
maternal mortality estimated on basis of expected
births increased from 135 to 166, which Thuriaux and
Lamotte2 consider an indication of how misleading the
institutional maternal mortality ratio can be. However,
it is more likely that the increased coverage of institu-
tional births also improved recording of maternal
deaths, which is presumably not close to 100% as can
be expected from the low general level of obstetric
coverage in Niger. To use absolute numbers of deaths
is, therefore, misleading if one does not take changes in
obstetric coverage into account.
Finally, it is noted that in Niger, where female life
expectancy was estimated at 45.0 years for 198O-85,5
278 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
maternal death are unlikely to cause less than 10% of
all death among women aged 15-49 years.6'7 Using
model life tables8 it can be estimated that, if maternal
mortality in Niger is 150 per 100000 live births,
maternal causes contribute less than 4% to total
mortality among females in their reproductive ages.
Ten per cent corresponds with a maternal mortality of
440 per 100000 live births which suggests that record-
ing of maternal deaths is not significantly better than
recording of deliveries.
REFERENCES
1 8
Thuriaux M C, Lamolle J M. Maternal mortality in developing
Chronic lymphocytic leukaemia: an unexpected high incidence
rate in Burgundy (France)?
From P M CARLI
Sir—All cases of haematopoietic malignancies diag-
nosed since 1 January 1980 have been collected in a
population based registry limited to malignant haemo-
pathies in the department of C6te d'Or, France
(478000).
In the course of five years, 127 cases of chronic
lymphocytic leukaemia (CLL) (79 males and 48
females) have been registered. In males, CLL ranks
first (20% of the cases) before non-Hodgkin's
lymphomas (16%), acute leukaemias (15%), multiple
myeloma (12%). In females, CLL ranks third (16%)
after multiple myelomas (17%), acute leukaemias
(17%), as non-Hodgkin's lymphomas (16%). One of
the major problems faced by cancer registries is the
determination of completeness and reliability of the
data. Because of the enthusiastic participation of the
medical profession in the department, we assume that
nearly all newly diagnosed CLL were registered. It has
been verified that there were no prevalent cases among
the registered cases.
Compared to other cancer registries, the rates
reported in C6te d'Or are the highest in the world for
both males and females.1 There are two possible
explanations for such an intriguing situation. One is
that the incidence of CLL in Cdte d'Or does not differ
from that of other places, but the reporting of CLL
Laboratoire d'Hemalologie, Centre Hospitalier Regional, 2 Bd Mai de
Latlre de Tassigny, 21034 Dijon Cedex—France.
countries. A note on the choice of denominator. Int J
2
Epidemiol 1984; 13: 246-7.
Thuriaux M C, Lamotte J M. Maternal mortality in developing
countries. Int J Epidemiol 1985; 14: 485-6.
3
Royston E, Ferguson J. The coverage of maternity care: a critical
review of available information. World Health Slat Quart
1985; 38: 267-89.
4
Grech E S, Galea J, Trussell R R. Maternal mortality. In: Hall S A
and Langlands B W (eds). Uganda atlas of disease distribution.
East Africa Publishing House, Nairobi, 1975, pp 126-9.
5
UN demographic indicators of countries: estimates and projections
as assessed in 1980. New York, 1982.
6
Preston S H. Mortality patterns in national populations. Academic
Press, New York, 1976.
7
Rinehart W, Kols A. Healthier mothers and children through family
planning. Population Reports Series J 27, 1984.
UN model life tables for developing countries. New York, 1984.
cases is better in C6te d'Or. The other is that CLL is
really more frequent in Cote d'Or.
Part of the variation in incidence presumably arises
from different criteria for the diagnosis of CLL: Rai's
criteria2 required a peripheral lymphocyte count
>15000/ml whereas Binet's criteria3 is an initial
lymphocyte count >4000/fnl. We have applied the
latter classification. The other population based French
registries using the same classification have lower rates.
It is possible that some cases are wrongly registered as
well-differentiated lymphocytic lymphomas in other
registries. But the rates of lymphomas are not higher in
other registries than in ours.
The proportion of the registered patients detected
during a biological investigation including a systematic
leucocyte differential account was 56.5%. No available
comparison is found in the literature.
Case-control studies are necessary to search for
environmental and occupational factors. The results
could explain the high incidence rate observed in our
department.
REFERENCES
1
Waterhouse J, Muir C, Shanmugaratnam K, Powell J. Cancer
incidence in five continents 1982, Vol IV. Lyon, IARC
Scientific Publications, No 42.
2
Ray K, Sawitsky A, el al. Clinical staging of chronic lymphocytic
leukemia. Blood 1975; 46: 219-34.
3
Binet J L, Leporrier M, el al. A clinical staging system for chronic
lymphocytic leukaemia. Cancer 1977; 40: 855-64.
 LETTERS TO THE EDITOR 279

Education and prevalence of smoking in Italian men and women

From CARLO LA VECCHIA, ADRIANO DECARLI AND ROMANO PAGANO

Sir—Copies of the original computer tapes of the TABLE 1 Age-standardized' per cent distribution of current and ex
Second National Health Survey (kindly provided by the smokers among Italian males and females aged 25 or over according to
education. 1983 National Health Survey.
Central Institute of Statistics) were used to investigate
the relation of smoking status with education in Italian Completed education:
males and females. This survey was conducted between Sex and Primary Middle High
28 November and 3 December 1983 on a sample of smoking status None school school school University
31025 households (a total of 89756 people) randomly
Males
chosen within the strata of a geographical area (region),
Current smokers 49.4 50.1 49.0 46.4 40.8
size of municipality and size of household, in order to Ex-smokers 14.3 16.7 17.7 18.1 17.0
be representative of the general Italian population. (3212)t (12102) (6316) (4386) (1639)
Interviews were arranged and conducted within the
Females
houses of the families selected by civil servants Current smokers 8.9 14.8 24.2 27.8 29.1
appointed by each municipality included in the study. Ex-smokers 1.1 2.0 4.4 6.1 7.1
The overall participation rate was 93.4% of the original (5961) (14075) (5623) (3840) (1017)
sample.1
* Directly standardized in 10-year age groups.
The age-standardized per cent rates of current and + Total numbers of subjects in each education category are given in
ex-smokers for Italian males and females (aged 25 or parentheses.
over) according to completed education are reported in
The 1983 Health Survey is the first available set of
Table 2. Among males, the prevalence of current
data showing a negative association between social
smokers was around 50% for those with less than a high
status (as indicated by education) and smoking
school certificate, and tended to diminish for those who
prevalence in Italian males, though the differences were
had finished high school (46%) or had a university
still smaller than in most North European or American
degree (41%). Cessation rates (ie the ratio of ex- to
countries, 2 ' 3 and overall smoking prevalence in males
ever-smokers) were positively related with education.
was higher in Italy (48.1 current, 16.5% ex-smokers).
Overall smoking prevalence was considerably lower The pattern observed in females (with a relatively low
in females (17.6% were current and 2.7% ex-smokers).
overall prevalence but a strong positive social class
However, smoking was much commoner among more
gradient) is largely at variance with that of several other
educated women, being three times more frequent
developed countries, and probably reflects the recent
among those with a university degree than among the
increase in smoking among Italian women.
least educated ones. Cessation rates, though generally
lower than those of males, were positively related with REFERENCES
1
education in women, too. For both sexes, there was no Istituto Centrale di Statistica. Andamenio demografico e saniiario.
clear relation between education and number of 1ST AT Notiziario 1984; anno V, nos. 9-11, Sett-Nov.
2
Office of Population, Censuses and Surveys: Cigarette smoking:
cigarettes smoked per day.
1972 to 1982. OPCS Monitor 1983; July 5.
3
Remington R L, Forman M R, Gentry E M, el al. Current smoking
trends in the United States. The 1981-1983 behavioural risk
Mario Negri Insiiluie, Rome, Italy. factor surveys. JAMA 1985; 253: 2975-8.

From IAN W WEBSTER AND ROBYN RICHMOND

Sir—We appreciate Dr Colditz's attempt to cost the
benefits of our programme which support our view
that preventing cigarette-related diseases is not only of
benefit to health but has economic benefits.
If the value of the Australian dollar had not fallen so
far in relation to the US dollar, Dr Colditz's calcula-
tions might have favoured our claims for the smoking
School of Community Medicine, University of New South Wales, PO
Box 1, Kensington NSW, Australia 2033.
cessation programme even more.
We are presently carrying out cost-effectiveness
studies of our programme and other smoking cessation
programmes using direct costing methods, obviating
assumptions about the inputed value of life used in Dr
Colditz's calculations.
We believe that smoking cessation is a legitimate
objective for general practice and of great significance
for public health.